March 13th, 2018
The Lown Institute Vignette Competition challenges medical students and trainees to shine a light on everyday overuse and underuse – common practices that either give patients unnecessary tests and procedures, or that fail to give patients necessary care. Sharing stories of the downstream consequences of overuse can be a powerful counterbalance to the ‘more is better’ culture and can help clinicians recognize and avoid overuse.
This year, we received vignette submissions from students and trainees all over the country (and internationally!) on topics from avoiding polypharmacy to inappropriate stenting to navigating clinical guidelines.
We’re publishing the top vignettes on our website. Learn more about the competition and read all the vignettes here.
Jian Liang Tan, MD
Kshitij Thakur, MD
Crozer-Chester Medical Center, PA
A 76-year-old morbidly obese man with history of coronary artery disease, duodenitis, gastritis and small bowel arteriovenous malformations (AVMs) presented with symptomatic anemia. Recent outpatient capsule endoscopy revealed probable proximal jejunal AVMs. His hemoglobin (Hb) level at the time of presentation was 6.4 g/dL, compared with his baseline Hb of 10.3 g/dL. He was transfused a total of 2 units of packed red cells with the goal of keeping his Hb ≥ 8 g/dL. An upper endoscopy and push enteroscopy were planned. The patient lost his peripheral intravenous (IV) access on the day prior to procedure. Multiple attempts to re-establish a new peripheral IV access were unsuccessful. An electronic order for an interventional radiology (IR) placement of a triple lumen peripherally inserted central catheter (PICC) line was placed. He had the PICC line inserted fluoroscopically and subsequently had the gastrointestinal procedure performed the following day. PICC line removed a day later and patient was discharged from the hospital without having any procedure-related complications. The PICC line was in for a total of 36 hours only.
Health care costs in the United States have increased exponentially over the past years. The discussion on reducing waste in health care system is now a common theme in many medical conferences. An estimated $100 billion of wasteful spending is solely due to failures of care delivery (the waste that was a result of poor execution or lack of widespread adoption of known best care processes).1 Bentley et al2 estimated that at least $1 billion of health care spending was attributed to procedure-specific clinical waste. Initiatives like Choosing Wisely campaign and American College of Physicians High Value Care curriculum are aimed to educate health care providers about health care waste and to promote cost-effective medicine.3
PICC is, a central venous catheter, commonly used for patient needing a prolonged period of IV therapy in the inpatient and outpatient settings. The use of PICCs has drastically increased over the past years, with over 2 million of PICCs are inserted each year in the acute care hospitals in the United States.4 While PICC offer convenience and comfort, like any other central venous catheters, the placement of PICC is certainly not without risk. PICC-related complications include immediate (vascular, cardiac, and pulmonary-related) and late (infection and thrombosis) which often result in morbidity, mortality, and higher healthcare cost.5 National average cost for the placement of a PICC line in an IR suite could easily costs between $450-$3000.6,7 It was estimated that 1000 PICCs per year would cost a hospital $1,228,598 to manage PICC-related maintenance and complication.4
A survey conducted by Vineet Chopra et al revealed that hospitalist knowledge regarding PICC-related complications was poor and close to 50% of hospitalists indicated that ¼ of the PICCs inserted were inappropriate.9 A multispecialty panel, led by Vineet Chopra, MD, of the University of Michigan, had established the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) guideline to define best practices for PICC use, care and management.10 The guideline advocated that use of PICC was considered appropriate for patients needing venous access of ≥6 days but it was highly preferred when the proposed duration was 15-31days. The guideline also stated the specific venous access device recommendations for patient with difficult venous access. An ultrasonography-guided peripheral IV catheters and midline catheters were preferred over PICC when the proposed duration of use was ≤14 days. Hence, the use of PICC line for ≤ 5 was rated as inappropriate for all indications. As in our patient, ultrasonography-guided peripheral IV catheters and midline catheters should have been tried prior to proceeding with PICC line insertion.
The placement of a multi-lumen PICC is considered appropriate in patient receiving concurrent IV medications with vasopressors, total parental nutrition, multiple incompatible medications or irritant chemotherapy. Otherwise, the use of single-lumen PICC is highly recommended. According to David Ratz et al, every 5% reduction in the use of multi-lumen PICC would prevent 0.5 PICC-related deep vein thrombosis and bloodstream infection events respectively, while saving an estimated cost of $23,500.8 Literatures have associated the number of PICC-lumens with the risk of adverse events (DVT and bloodstream infection). Hence, ensuring the appropriate use of multi-lumens PICC is important to avoid these costly adverse events. As in our patient, placing a triple-lumen PICC solely for the infusion of IV compatible medications was considered inappropriate.
MAGIC application, an easy to use mobile application, was created to guide a clinician in choosing the appropriate vascular access device and to improve decision-making in vascular access. Physicians are encouraged to use it at the point-of-care prior to ordering PICCs.10
Given the rising trend of inappropriate use of PICCs, we encourage the clinicians to take a “time-out” to think about the selection of appropriate venous access devices at all time to provide a cost-effective medicine to the patients without jeopardizing their safety.